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EIVED,5 Monitoring Y Equipment System E ment Certi ication p P'or Use ByAll.lurisdictions 6Yithin The State of California vt_ L 12 ?014 Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California �Code of Regulations This formust be used to document testing and servicing of monitoring equipment. A separate certihcatiiiform or report mast be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provid�ALTH to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST sysie within 30 days of test date. A. General Information Facility Name: Safeway Bldg. No.: Sitc Address: 1987 W. 11th St. City: Tracy, CA "Lip: 95376 - Facility Contact Person: Will Contact Phone No.: (209) 830-2950 Make/Model of Monitoring System: VR TLS -350 Date of Testing/Servicing: 11/13/14 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: "Tank III; Tank lQq ❑ In - Tank Gauging Probe. Model: ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill \ High -Level Sensor. Modes: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section Eon Page 2) ❑ Other ( specify equipment type and model in Section Eon Page 2). Tank IQ: Tank ❑ ID• In - Tank Gauging Probe. Nlodel ❑ In - Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump \ Trench Sensor (s). Model: ❑ Piping Sump \ Trench Sensor (s). Model• ❑ Fill Sump Sensor (s). Model: ❑ Fill Sump Sensor (s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Llectronic Line Leak Detector. Model: _ p Tank Overfill \ High -Level Sensor. Model: ❑ Tank Overfill \ High -Level Sensor. Model: ❑ Other ( specify equipment type and model in Section E on Page 2) ❑ Other ( specify equipment type and model in Section E on Page 2) Dispenser ID• 13-14 Dispenser ID' 15-16 Ig Dispenser Containment Sensor (s). Model:VR 794330-20e ® Dispenser Containment Sensor (s). Model. VR 79_4380-208 ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser iD• 17-18 Dispenser ID• 19-20 M Dispenser Containment Sensor (s). Model VR 7943110-208 JW Dispenser Containment Sensor (s). Model: VR 794360.208 ❑ Shear Valve (s) ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s). ❑ Dispenser Containment Float (s) and Chain (s). Dispenser ID, Dispenser iD' ❑ Dispenser Containment Sensor (s) Model: ❑ Dispenser Containment Sensor (s). Model: ❑ Shear Valve (s). ❑ Shear Valve (s). ❑ Dispenser Containment Float (s) and Chain (s) ❑ Dispenser Containment Float (s) and Chain (s). "if the facility contains more tanks or dispensers, copy this form. include information for every tank and dispenser at the facility C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturer's guidelines. Attached to this Certification is information (e.g. manufactures' checklists ) necessary to verify that this information is correct and a Plot Plan showing the layout or monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the; (check all that apply): (@ System set-up 00 Alarm history report Technician Name (print): Kris Bell Signature: Mfg. Cert.#. B33709 ICC# 5297793 -UT License. No.: 485184 Testing Company Name: Service Station Systems Phone No.: 408) 971-2445 Testing Company Address: 680 Quinn Ave., San Jose, CA 95112 Date of Testing/Servicing: 11/13/14